Spinal Injury

Question 1

What are the three care objectives in SCI?

Answer 1

1. Identify SCI and transfer to appropriate facility
2. Protect and support spinal column integrity where SCI/unstable vertebral injury unable to be excluded
3. Avoid unnecessary immobilization by excluding pts without spinal injury

Question 2

What is the intent behind spinal immobilisation?

Answer 2

The intent of spinal immobilisation is to support the neutral alignment of the spinal column and reduce or distribute forces placed on it.

Question 3

For what reasons might a collar not achieve the desired support, and what can be done about this?

Answer 3

Pt’s anatomy doesn’t permit, pt agitated.

Can be adjusted, loosened or removed if no other options.

Question 4

What is the optimal position for spinal immobilisation? Which patients might this not be possible and how should it be managed?

Answer 4

Supine.

Question 5

Which patients might it not be possible to place supine for spinal immobilisation and how should it be addressed?

Answer 5

May not be possible due to pain, vertebral disease, kyphosis, injuries prevent the position, CCF.
Support the pt in a POC.

Question 6

Can patients be transported on a CombiCarrier board after extrication?

Answer 6

No, pts must be removed from board for transport.

Question 7

What note is made about restraining the head for spinal immobilisation?

Answer 7

The head must not be independently restrained to the stretcher.

Question 8

List the 4 “Concerning” potential mechanisms of movement for a ?spinal pt.

Answer 8

1. Hyperflexion
2. Hyperextension
3. Hyperrotation
4. Axial loading of the spinal column

Question 9

What are the 4 MOI’s that should infer concern for damage to a healthy vertebrae?

Answer 9

1. Car rollover
2. Car ejection
3. Pedestrian impact
4. Diving accident

Question 10

After trauma of any kind, which patients should be treated with a high index of suspicion for unstable cervical spine injuries?

Answer 10

1. Older pts
2. Pts with a Hx of vertebral disease/spinal abnormality eg.
   a. ankylosing spondylitis
   b. spinal stenosis
   c. spinal fusion
   d. previous c-spine injury
   e. rheumatoid arthritis

Question 11

Pts with penetrating trauma should…?

Answer 11

Not be routinely immobilised. Consider immobilisation only were demonstrable neurological deficit.

Question 12

An altered conscious state under the Spinal Injury guideline includes…?

Answer 12

Any presentation that may confound the results of a physical examination e.g GCS <15 for any reason, concussion, dementia.

Question 13

What should be considered for prophylaxis in spinally immobilised pts?

Answer 13

Antiemetics, for all awake, immobilised pts.

Question 14

What immediate indications require a pt to be spinally immobilised?

Answer 14

MOI/traumatic injury with potential for SCI
+
Meets MTC after blunt force trauma to head/trunk
OR
Neurological deficit/changes

Question 15

Under the Spinal Injury guideline, what are the 4 elements and 7 subsets for the modified Nexus criteria?

Answer 15

1. Increased Injury Risk
   - Age ≥65
   - Hx bone/muscle weakening disease/injury
2. Difficult Pt Assessment
   - Altered conscious state
   - Intoxication
   - Significant distracting injury
3. Actual Evidence of Structural Injury
   - Midline pain on palpation of vertebrae
4. Neck Range of Motion
   - Pt is unable to actively rotate neck 45º left/right without pain

Question 16

How is a pt spinally cleared?

Answer 16

None of the modified NEXUS criteria are present.

Question 17

If a pt is immediately indicated for immobilisation (neuro deficit or meets MTC), what is the management?

Answer 17

1. Apply cervical collar
2. Extricate with combi if necessary
3. Immobilised on vacuum mattress/stretcher
4. Tx without delay (time critical)
5. Consider antiemetics

Question 18

In conjunction with standard process for pts immediately requiring immobilisation, what additional managements should be enacted in the presence of an isolated SCI?

Answer 18

If BP <90mmHg, Normal Saline 10ml/kg IV

Question 19

If the pt does not meet the criteria for immediate immobilisation, but is unable to be cleared via the modified NEXUS, what is the management?

Answer 19

1. Apply cervical collar
2. Extricate on combi if necessary
3. Consider self extrication where the pt is conscious/cooperative, not intoxicated and not prevented from doing so by injury
4. Immobilise to vacuum mattress or stretcher
5. Consider antiemetics

Question 20

In what circumstances is self-extrication appropriate in the pt requiring spinal immobilisation due to presence of NEXUS elements?

Answer 20

1. Conscious and cooperative
2. Not intoxicated
3. Not prevented from doing so by injury

Question 21

How should neurological function be examined for the NEXUS criteria?

Answer 21

1. Motor Function (assess for any weakness)
   Arms - push, pull, grasp
   Legs - plantar flex (push), dorsiflex (pull), leg raise
2. Sensory Function (assess for altered sens.)
   Arms - light touch to palms/ back of hand
   Legs - touch lateral aspect of calcaneus
   (side of heel)
   Suprasternal notch - light touch
3. Any other numbness, tingling, burning, altered sensation.

Question 22

If any neurological alterations per the NEXUS exam present then…?

Answer 22

Pt can not be spinally cleared.

Question 23

Should left and right sides be assessed for deficit separately or simultaneously?

Answer 23

Simultaneously.

Question 24

If weakness or inability to perform the test due to pre-existing condition then…?

Answer 24

Assess against the pts normal, baseline function.